Socioeconomically Disadvantaged Children Experience Gaps in Vision Screening

Isdin Oke, MD, MPH

Credit: Harvard Ophthalmology

A new cross-sectional study provides novel insight into the stark gaps in the vision screening pathway among school-aged children in the United States belonging to socioeconomically disadvantaged groups.¹

At each stage of the vision screening pathway, the cross-sectional data showed children from historically vulnerable groups were less likely to receive screening, more likely to be referred for failure screening, and less likely to establish care with an eye care specialist.

“The cumulative effect of each step along the pathway may contribute to the racial, ethnic, and socioeconomic disparities in visual outcomes that are already evident by adolescence,” wrote the investigative team, led by Isdin Oke, MD, MPH, Boston Children’s Hospital.

Children in the US may receive vision screening in multiple settings, including primary care clinics, schools, and community events. But the wide array of approaches and variability in screening policies, are thought to result in missed care for children with preventable vision loss. Failures in the vision screening pathway are often poorly understood, so Oke and colleagues set out to identify gaps in a nationally representation survey of the US pediatric population.

School-aged children from the 2021 National Survey of Children’s Health (NSCH), a nationally representative survey of the noninstitutionalized US pediatric population, were included for analysis. Vision screening questions were updated in that survey year, to allow for analysis of the vision screening pathway, including the receipt of screening, referral for eye examination, and establishment of specialty care.

Sociodemographic variables, including age, sex, race, ethnicity, insurance type, household income, caregiver education level, household generation, and primary household language, were collected for analysis. The investigative team used survey weights to account for the NSCH sampling design, participant counts, and survey-weighted percentages.

Overall, the demographic characteristics of 30,173 children were summarized in the analysis. A total of 18,494 participants reported vision screening within the past 2 years (survey-weighted 61%) and among those screened, 5134 (survey-weighted 30%) were referred for an eye examination. From the referral population, 4823 (survey-weighted 92%) reported care with a specialist.

Upon analysis, investigators found children identifying as Hispanic, non-Hispanic Asian, or non-Hispanic Black, or residing in low-income households and with a non-English primary household language, were less likely to receive vision screening. As a result, these patients were more likely to receive a referral for eye examination, but still less likely to receive care from a specialist.

Other patient cohorts, including adolescents, children without health insurance, and children with caregivers with less than a high school education, were also less likely to receive screening. Again, these children not receiving screening were more likely to be referred for an eye examination.

Oke and colleagues noted the high referral rates among more vulnerable populations likely suggest a greater prevalence of undiagnosed conditions or elevated false-positive results from suboptimal screening methods. They suggested these data provide evidence of inequitable opportunities for access to vision care and lack of experienced care are most often faced by socioeconomically disadvantaged populations.

“Novel strategies are needed to improve our ability to identify children at greatest risk of preventable vision loss,” Oke wrote.

References

1. _{Oke I, Slopen N, Galbraith AA, Hunter DG, Wu AC. Gaps in the Vision Screening Pathway for School-Aged US Children. JAMA Ophthalmol. Published online January 25, 2024. doi:10.1001/jamaophthalmol.2023.6316}
2. _{Iapoce C. Study: 1 in 4 US adolescents did not receive vision testing in the past year. HCP Live. October 20, 2023. Accessed January 25, 2024. https://www.hcplive.com/view/study-1-4-adolescents-did-not-receive-vision-testing-past-year.}